Report: Jails Could Have Prevented Inmate Death

January 9, 2009

In 2007, the Voicedetailed the death of Oswald Livermore in the city jail known as “the tombs.” Livermore died from acute alcohol withdrawal with delirium tremens on May 11 of that year. His family alleged misconduct by guards and medical personnel in connection with the death.

Now, the top state agency charged with monitoring jails and prisons has finally issued a detailed report on the incident.

Obtained through a Freedom of Information request, the heavily redacted state Commission on Correction report finds that Livermore’s death may have been prevented if medical officials in the jails had simply diagnosed the condition and treated it.

Medical care in the jails is supplied by Prison Health Services, a
private contractor. And according to the commission, they dropped the
ball.

Commission investigators found that Livermore’s condition was not only
untreated, but unrecognized–even though his paranoid ramblings and
thrashing in his cell were both clear indications that something was
seriously wrong.

“The conclusions in the report track the allegations in the federal
lawsuit, that they failed to comply with their own protocol,” says
Jonathan Chasen, a Legal Aid lawyer representing Livermore’s widow.

Specifically, when he was brought into the jail, Livermore reported
that he was a heavy drinker. But the person examining him failed to
follow a city requirement that a special form be added to his file, the
report says. In addition, the medical staffer failed to evaluate him
for alcohol withdrawal symptoms–another violation of city rules.

Livermore started behaving erratically less than 24 hours after his
arrival in the system. At 10 p.m. on May 10, a guard referred him to
mental health. While waiting in a holding area, he was anxious, crying,
sweating, disoriented and paranoid.

A captain ordered him to the medical clinic. What happened there has
been redacted, but for some reason, he was ordered back to his cell
three hours later. That was a huge mistake.
In the cell, Livermore
began hitting and kicking the walls and making paranoid statements, the
report says. An officer brought him out of his cell, where Livermore
promptly ran down a staircase and fell heavily. Then, he began saying
that the police were coming to get him, and they wanted to operate on
his penis.

An officer and an inmate tried to hold him still. He jumped up and ran
to the other end of the unit. Two officers forced him to his knees and
handcuffed him.

What happened after that is redacted.

The commission asked the Health Department to investigate the actions
of two PHS medical employees, and come up with a way to improve
communication in the medical operation at the jails.

We called the Department of Correction for comment, but have yet to hear back.